Title: Third Time Aortic Valve Replacement in a Patient with a Totally Calcified (Porcelain) Aortic Homograft.Authors: Travis C Geraci, MD, Mikhail Vaynblat, MDAbstractObjective: Homograft aortic root replacement provides an excellent hemodynamic restoration of valve function for prosthetic aortic valve endocarditis, but is susceptible to degeneration and calcification. The optimal surgical intervention for valvular disease after homograft root replacement is controversial due to the high risk of morbidity and mortality with reintervention.Methods: This video demonstrates a case of re-do sternotomy with mechanical aortic valve replacement (AVR) in a patient post two previous AVRs and a porcelain homograft. A 38-year old female presented in heart failure from prosthetic valve endocarditis, with a history of systemic lupus erythematosus (SLE), complicated by end-stage renal failure requiring dialysis and lupus anticoagulant.Results: The patient had severe prosthetic aortic insufficiency, severe mitral regurgitation, and severe tricuspid regurgitation. A third-time redo sternotomy was performed. A mechanical sized #17 valve was placed in the aortic position and a #23 sized mechanical valve was placed in the mitral position. A bovine patch aortoplasty of the aorta was required after the calcified wall shattered into fragments upon transection with a patch of bovine pericardium. Postoperative ECHO revealed preserved LV and RV function with good function of the mechanical aortic and mitral valves.Conclusions: Mechanical AVR, without replacement of the aortic root, is a feasible and potentially effective method of reestablishing a functional aortic valve in a patient with a severely calcified aortic homograft.